Mannitol is an osmotic diuretic, which is used clinically in osmotherapy to reduce acutely raised intracranial pressure, thus, this drug has very high usage in the neurosurgical ward. When room temperature is below 25 degree Celsius, crystals formed in the bottle and crystals also formed within the infusion control set. In order to melt the crystals, health care workers heated both the Mannitol bottle and the infusion control set in a water bath,(by tying Mannitol bottle and the infusion

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... set together). So the water in the water bath penetrates into the infusion control set. Results: After shifting to double boiler, this kind of contamination does not occur. Conclusions: In medical area, even tiny or mindless inappropriate procedure can induce serious and fatal result just like Bacteremia can have several consequences. As Infection control practitioners, we should always keep alert when find unusual infections, and carry out investigations immediately.